Sarcopenic Obesity in Chronic Kidney Disease: Challenges in Diagnosis Using Different Diagnostic Criteria

Body Composition and Intradialytic Exercise in Kidney Disease: A Combined Analysis of the PEDAL and CYCLE-HD Randomised Controlled Trials

BACKGROUND

Haemodialysis patients are at high risk of myopenic obesity, necessitating effective nutritional status monitoring and intervention strategies. This combined analysis of two clinical trials (PEDAL trial and CYCLE-HD study) aimed to (i) determine the clinical utility of body mass index (BMI) in comparison to fat tissue index (FTI) and lean tissue index (LTI) and (ii) assess the effect of a 6-month intradialytic exercise intervention compared to usual care on FTI and LTI.

METHODS

A priori secondary endpoints in both trials included BMI, FTI and LTI. BMI was classified by World Health Organisation definitions (underweight, healthy, overweight or obese). FTI and LTI were determined by Bioelectrical Impedance Spectroscopy and classified by previous research evidence (FTI of 4-15 kg/m2 and LTI of 15-20 kg/m2 being associated with best survival). For aim (i), BMI was compared to FTI and LTI by correlation and classification. For aim (ii), changes over 6 months in FTI and LTI were compared between exercise intervention and control groups.

RESULTS

Across both studies, 298 and 209 participants had bioelectrical impedance spectroscopy measurement at baseline and 6 months, respectively. Mean (SD) age: 58 (15) years; BMI: 28.2(6.3) kg/m2; male: 65%. At baseline, only 47 of 298 participants (16%) had an FTI and LTI associated with best survival. BMI correlated with FTI (r = 0.79; p < 0.0001). However, 34% of participants were misclassified by BMI (e.g., 9% of patients were classified as obese by BMI yet FTI revealed their body composition was healthy). BMI did not correlate with LTI (p = 0.15), and 86% of participants were misclassified by BMI (e.g., 73% of patients were classified as healthy, overweight or obese by BMI yet LTI revealed they were myopenic). There was no difference between exercise intervention and control groups in mean change (95% CI) over 6 months for LTI (-0.3 [-1.1 to 0.4] kg/m2; p = 0.4) or FTI (0.2 [-0.7 to 1.0] kg/m2; p = 0.7).

CONCLUSIONS

Worryingly, only a minority (16%) of haemodialysis patients had both LTI and FTI within the range associated with best survival. Body composition misclassification using conventional BMI cut-offs was common: despite having healthy, overweight or even obese BMI, the majority (73%) of patients had hidden myopenia according to LTI. Six months of intradialytic aerobic exercise did not improve body composition. This study identified that common measures of nutritional status in haemodialysis patients such as BMI are misleading and that interventions other than intradialytic cycling are urgently required to target myopenic obesity.

Nutritional Intake and Diet Quality in Hemodialysis Patients: Scope for Improvement

OBJECTIVE

Hemodialysis (HD) patients face challenges in upholding dietary compliance. This study aimed to compare dietary intake against disease-specific guidelines. Secondary, to assess the overall diet quality and to explore the association between dietary potassium intake and serum potassium concentrations.

METHODS

In this cross-sectional multicenter study, nutrient intake of Dutch adult HD patients was assessed using food frequency questionnaires and diet quality with the Dutch Healthy Diet 15-index. Intake and diet quality were compared to disease-specific dietary recommendations or Dutch Dietary Guidelines. Insufficient intake was defined as <90% of the requirement, sufficient as 90-100%, and excessive as >110%. The association between serum potassium concentration and dietary potassium intake was modeled with linear regression analysis.

RESULTS

The study population consisted of 248 participants (60% male) from 21 dialysis centers. Energy intake (1789 [872] kcal/day) was insufficient for 45% of the participants, while protein intake (1 [0.5] g/kg/d) was insufficient for 50%. Despite 67% of participants managing to align their energy intake below 110% of the recommended level, a high prevalence of overweight (61%) was observed in this cohort. Saturated fat intake was excessive for 87% of participants, while only 15% met the recommended fiber intake. Overall diet quality was low (74 [20] maximum score of 150). No association was observed between serum potassium and dietary potassium intake after adjusting for relevant confounders (r = 0.163, P = .261).

CONCLUSIONS

A considerable proportion of Dutch HD patients were unable to meet disease-specific dietary guidelines. Diet quality was shown to be poor.

The role of lean body mass in predicting mortality in hemodialysis patients across different age groups

Lean body mass (LBM) serves as an indicator of muscle mass in body composition. Recently, studies have revealed increased mortality rates in dialysis patients with low LBM. However, studies analyzing the impact of age on LBM and mortality in dialysis patients remain limited. This study analyzed data from 26,625 adult hemodialysis patients registered in the Korean Society of Nephrology (KSN) registry from 2001 to 2020. We used the lean body mass index (LBMI), standardized by the square of height, to normalize lean body mass. Patients were first categorized by age group (20-49, 50-69, and ≥ 70 years). Subsequently, patients were categorized into quartile groups based on their LBMI (≤ 15.55, 15.55 < LBMI ≤ 16.52, 16.52 < LBMI ≤ 17.59, and > 17.59). This study revealed that the lowest LBMI group (≤ 15.55) was associated with decreased survival across all age groups, with this trend being particularly prominent in the older age groups. Within the 20-49 age group, factors such as diabetes exhibited a notable influence on mortality rates among hemodialysis patients. In the age group over 50, a low LBMI (≤ 15.55) had a greater impact on mortality rates in hemodialysis patients than diabetes. Understanding the importance of LBM in older patients undergoing dialysis is crucial for improving their prognosis.

Prevalence, Characteristics, and Outcomes of People With A High Body Mass Index Across the Kidney Disease Spectrum: A Population-Based Cohort Study

Background

Obesity has a major impact on health and health care, particularly in those with chronic kidney disease (CKD).

Objective

The objective was to describe the prevalence, characteristics, and outcomes of people living with CKD and obesity (defined by a body mass index [BMI] ≥30 kg/m2) in Canada.

Design

Population-based cohort study using linked administrative health data (ICES).

Patients

Adults aged 18 year and older with CKD G1-5D who had a height and weight recorded during a visit to an academic hospital in London Ontario Canada, between January 2010 and December 2019.

Measures

CKD as defined by CKD 3A or higher. BMI as defined by weight kg/m2.

Methods

As a primary interest, we described the percentage of patients with CKD across different BMI categories (<25 kg/m2, BMI 25-29.9 kg/m2, and BMI ≥30 kg/m2), as well as their demographic and clinical profiles. As secondary interests, we followed patients until January 1, 2022 to summarize: (1) the percentage with CKD G3 who had kidney disease progression (50% decline from baseline estimated glomerular filtration rate [eGFR]) by BMI category, (2) the percentage with CKD G3-4 who developed kidney failure (initiation of maintenance dialysis or an eGFR of <15 mL/min/1.73 m2) by BMI category, (3) the percentage with CKD G4-G5D who received a kidney transplant by BMI category, and (4) post-transplant outcomes in those transplanted over the study period, by BMI category. We performed similar analyses across CKD risk categories.

Results

Of the 198 151 patients included, the percentage with obesity defined by a BMI ≥30 kg/m2 increased from CKD G1 to CKD G4 (ie, 37% of those with CKD G1 had a BMI ≥30 kg/m2 vs 40.9% of CKD G4). In CKD G5D and CKD T, the prevalence of high BMI appeared to drop (only ~38% had a BMI ≥30 kg/m2 across groups). Across CKD categories, those with a BMI ≥30 kg/m2 appeared to have more comorbidities, use more health care resources, and have more socioeconomic disparities than those with lower BMIs. Although secondary outcome events were limited, those with G3-4 with a BMI ≥30 kg/m2 appeared to have a higher risk of CKD progression and those with CKD G5D with BMI ≥30 kg/m2 were less likely to receive transplant over the study period. Interestingly those transplanted with a BMI ≥30 kg/m2 appeared to have fewer post-transplant complications. We also observed an "obesity-paradox" in the risk of mortality, with high BMI appearing protective, particularly in the end stages of kidney disease.

Limitations

We used BMI to capture obesity in this study but recognize its limitations as a measure of body composition. Secondary outcomes were descriptive and unadjusted due to small sample size and may have been subject to selection bias and confounding.

Conclusions

Obesity defined by high BMI is highly prevalent in people with CKD, and patients have health, health care, and social disparity. Future studies to understand the impact of BMI on patients with CKD and how to individualize and manage BMI and obesity across the spectrum of CKD remain important.

Muscle Mass and Muscle Strength in Non-Dialysis-Dependent Chronic Kidney Disease Patients

Background: Sarcopenia is a state with a progressive and generalized loss of skeletal muscle mass and strength. However, muscle strength and muscle mass are different features, which are usually not studied separately. The aim of the study was to investigate anthropometric and clinical correlates and sources of variation in both skeletal muscle mass and muscle strength in chronic kidney disease (CKD). Methods: The study sample consisted of 84 patients with an estimated glomerular filtration rate (eGFR) < 45 mL/min/1.73 m2. Muscle strength was estimated by measuring hand grip strength (HGS). Muscle quantity was measured with bioimpedance spectroscopy (BIS). Serum creatinine, urea, uric acid (UA), and albumin were measured as well. Results: Appendicular skeletal muscle mass (ASM) significantly and positively correlated with body mass, NH weight (normally hydrated weight), height, body mass index (BMI), lean tissue mass (LTM), lean tissue index (LTI), fat mass (FM), and fat tissue index (FTI), and was negatively associated with hydration status. HGS significantly and positively correlated with body mass, NH weight, height, LTM, LTI, and ASM, and was negatively associated with UA and urea. After adjustment for age, sex, and height, HGS remained significantly and negatively related with UA and hydration status. Conclusions: In CKD patients, ASM is determined by anthropometric parameters, but HGS is determined by both anthropometric and clinical variables specific for CKD. In order to study the determinants of HGS in CKD, relationships with HGS should be adjusted for anthropometric variables.

Exploring Adiposity and Chronic Kidney Disease: Clinical Implications, Management Strategies, Prognostic Considerations

Obesity poses a significant and growing risk factor for chronic kidney disease (CKD), requiring comprehensive evaluation and management strategies. This review explores the intricate relationship between obesity and CKD, emphasizing the diverse phenotypes of obesity, including sarcopenic obesity and metabolically healthy versus unhealthy obesity, and their differential impact on kidney function. We discuss the epidemiological evidence linking elevated body mass index (BMI) with CKD risk while also addressing the paradoxical survival benefits observed in obese CKD patients. Various measures of obesity, such as BMI, waist circumference, and visceral fat assessment, are evaluated in the context of CKD progression and outcomes. Mechanistic insights into how obesity promotes renal dysfunction through lipid metabolism, inflammation, and altered renal hemodynamics are elucidated, underscoring the role of adipokines and the renin-angiotensin-aldosterone system. Furthermore, the review examines current strategies for assessing kidney function in obese individuals, including the strengths and limitations of filtration markers and predictive equations. The management of obesity and associated comorbidities like arterial hypertension, type 2 diabetes mellitus, and non-alcoholic fatty liver disease in CKD patients is discussed. Finally, gaps in the current literature and future research directions aimed at optimizing the management of obesity-related CKD are highlighted, emphasizing the need for personalized therapeutic approaches to mitigate the growing burden of this intertwined epidemic.

Vascular Impairment, Muscle Atrophy, and Cognitive Decline: Critical Age-Related Conditions

The triad of vascular impairment, muscle atrophy, and cognitive decline represents critical age-related conditions that significantly impact health. Vascular impairment disrupts blood flow, precipitating the muscle mass reduction seen in sarcopenia and the decline in neuronal function characteristic of neurodegeneration. Our limited understanding of the intricate relationships within this triad hinders accurate diagnosis and effective treatment strategies. This review analyzes the interrelated mechanisms that contribute to these conditions, with a specific focus on oxidative stress, chronic inflammation, and impaired nutrient delivery. The aim is to understand the common pathways involved and to suggest comprehensive therapeutic approaches. Vascular dysfunctions hinder the circulation of blood and the transportation of nutrients, resulting in sarcopenia characterized by muscle atrophy and weakness. Vascular dysfunction and sarcopenia have a negative impact on physical function and quality of life. Neurodegenerative diseases exhibit comparable pathophysiological mechanisms that affect cognitive and motor functions. Preventive and therapeutic approaches encompass lifestyle adjustments, addressing oxidative stress, inflammation, and integrated therapies that focus on improving vascular and muscular well-being. Better understanding of these links can refine therapeutic strategies and yield better patient outcomes. This study emphasizes the complex interplay between vascular dysfunction, muscle degeneration, and cognitive decline, highlighting the necessity for multidisciplinary treatment approaches. Advances in this domain promise improved diagnostic accuracy, more effective therapeutic options, and enhanced preventive measures, all contributing to a higher quality of life for the elderly population.

The association of appendicular skeletal muscle mass with anthropometric, body composition, nutritional, inflammatory, and metabolic variables in non-dialysis-dependent chronic kidney disease men

Background

Muscle atrophy affects more than 50% of patients with chronic kidney disease (CKD) and is associated with increased morbidity and mortality. It is crucial to understand the mechanisms involved in the muscle atrophy in CKD and search for specific determinants of skeletal muscle mass loss, especially those which are available in everyday medical practice. This study aimed to evaluate the association between appendicular skeletal muscle mass (ASM) and anthropometric, body composition, nutritional, inflammatory, metabolic, and kidney function variables in non-dialysis-dependent CKD men.

Methods

A total of 85 men with CKD and eGFR lower than 60 mL/min/1.73 m2 were included in the cross-sectional study: 24 participants with eGFR 59-45 mL/min/1.73 m2, 32 individuals with eGFR 44-30 mL/min/1.73 m2, and 29 men with eGFR ≤29 mL/min/1.73 m2. ASM was estimated by bioimpedance spectroscopy (BIS) with the use of a Body Composition Monitor (BCM). To evaluate ASM from BCM, Lin's algorithm was used. Among anthropometric parameters, height, weight, and body mass index (BMI) were measured. Serum laboratory measurements were grouped into kidney function, nutritional, inflammatory, and metabolic parameters.

Results

ASM was significantly associated with anthropometric and body composition variables. According to the anthropometric parameters, ASM correlated positively with weight, height, and BMI (p < 0.001 and r = 0.913, p < 0.001 and r = 0.560, and p < 0.001 and r = 0.737, respectively). Among body composition variables, ASM correlated significantly and positively with lean tissue mass (LTM) (p < 0.001, r = 0.746), lean tissue index (LTI) (p < 0.001, r = 0.609), fat mass (p < 0.001, r = 0.489), and fat tissue index (FTI) (p < 0.001, r = 0.358). No other statistically significant correlation was found between ASM and kidney, nutritional, metabolic, and inflammatory variables.

Conclusion

In male patients with CKD stages G3-G5 not treated with dialysis, ASM correlates significantly and positively with anthropometric and body composition parameters such as weight, height, BMI, LTM, LTI, fat mass, and FTI. We did not observe such relationship between ASM and kidney function, nutritional, metabolic, and inflammatory variables.

Factors associated with sarcopenic obesity in Brazilian adults and older people: Systematic review and meta-analysis of observational studies

AIM

Sarcopenic obesity (SO) is characterized by the coexistence of the loss of muscle mass and function with excess adipose tissue. Its prevalence has increased concomitantly with population aging, becoming one of the most significant challenges for public health, threatening the quality of life and the physical and mental health of the elderly population.

METHODS

This study estimated the prevalence and factors associated with SO among adults and the elderly in Brazil's macro-regions, utilizing MEDLINE, Embase, Web of Science, and the Virtual Health Library databases. Primary outcomes included SO prevalence overall and by subgroups, with secondary outcomes identifying associated factors.

RESULTS

A systematic review of 33 studies with 10 266 participants up to July 2023 showed a 17% prevalence of SO (95% confidence interval: 13-21%), using a random effects meta-analysis. The Central-West region had the highest occurrence (27%). Dual-energy X-ray absorptiometry (26%) and bioimpedance (6%) were the top diagnostic methods. Protective factors were chronic kidney disease and healthy lifestyles; risk factors included socioeconomic status, functionality, lifestyle, biochemical parameters, and comorbidities such as osteoarthritis and apnea.

CONCLUSIONS

The prevalence of SO in Brazil is significant, emerging as a critical public health problem. It is essential to direct attention to changes in prevalence rates in the coming years, given the rising obesity trends and the absolute increase in the elderly population. Geriatr Gerontol Int 2024; 24: 661-674.

Are we ready for an adipocentric approach in people living with type 2 diabetes and chronic kidney disease?

We are entering a new era in the management of adiposity-based chronic disease (ABCD) with type 2 diabetes (T2D) and related chronic kidney disease (CKD). ABCD, T2D and CKD can affect almost every major organ system and have a particularly strong impact on the incidence of cardiovascular disease (CVD) and heart failure. ABCD and the associated insulin resistance are at the root of many cardiovascular, renal and metabolic (CKM) disorders, thus an integrated therapeutic framework using weight loss (WL) as a disease-modifying intervention could simplify the therapeutic approach at different stages across the lifespan. The breakthrough of highly effective WL drugs makes achieving a WL of >10% possible, which is required for a potential T2D disease remission as well as for prevention of microvascular disease, CKD, CVD events and overall mortality. The aim of this review is to discuss the link between adiposity and CKM conditions as well as placing weight management at the centre of the holistic CKM syndrome approach with a focus on CKD. We propose the clinical translation of the available evidence into a transformative Dysfunctional Adipose Tissue Approach (DATA) for people living with ABCD, T2D and CKD. This model is based on the interplay of four essential elements (i.e. adipocentric approach and target organ protection, dysfunctional adiposity, glucose homeostasis, and lifestyle intervention and de-prescription) together with a multidisciplinary person-centred care. DATA could facilitate decision-making for all clinicians involved in the management of these individuals, and if we do this in a multidisciplinary way, we are prepared to meet the adipocentric challenge.

Sex Differences in the Association of Weight-Adjusted-Waist Index with Sarcopenic Obesity: A Cross-Sectional Study of Hemodialysis Patients

Objective: To explore the association between weight-adjusted-waist index (WWI) and sarcopenic obesity (SO) in patients with maintenance hemodialysis (MHD). Methods: A multicenter, cross-sectional study that included 3311 adult MHD patients was conducted in 20 hemodialysis (HD) centers from June 1, 2021, to August 30, 2021. Body composition was evaluated by body composition monitor based on bioimpedance spectroscopy. Hand grip strength was measured by CAMRY® dynamometer. WWI was calculated as waist circumference (cm) divided by the square root of body weight (kg). Multiple logistic regression models, spearman correlation analysis, and receiver-operating characteristic (ROC) analyses were conducted. Results: The median age of the study was 55 years, and 39.4% of patients were female. The prevalence of SO was 22.7% in the total population, and patients with SO had higher WWI. Higher WWI quartiles were independently associated with a higher risk of SO in men after adjusting for potential confounders, including age, dialysis vintage, body mass index, biochemical indicators, and various medical histories; the odds ratio (OR) of SO was highest in the fourth quartile of the WWI (OR: 4.08, 95% confidence interval: 2.65-6.27, P for trend <0.001). Age-adjusted WWI provided a better diagnostic power than WWI only for SO in men (area under the ROC curve: 0.72 vs. 0.68, P < 0.001). WWI was not associated with SO in female HD patients. Conclusion: WWI is independently associated with SO in male but not female MHD patients. This anthropometric index is simple to calculate, making it applicable in clinical practice.

Decreased intracellular water is associated with sarcopenic obesity in chronic haemodialysis patients

OBJECTIVE

To explore the association between intracellular water (ICW) and sarcopenic obesity in patients undergoing chronic haemodialysis (HD).

METHODS

A multicentre, cross-sectional study of 3354 adult chronic HD patients was conducted in 20 haemodialysis centres from June 1, 2021, to August 30, 2021. The diagnosis of sarcopenic obesity was made according to the revised Asian Working Group's definition of sarcopenia combined with obesity per the body fat percentage definition. Body composition was evaluated by a body composition monitor using bioimpedance spectroscopy. Multiple logistic regression models, stratified analyses, interactive analyses, and receiver-operating characteristic analyses were conducted.

RESULTS

A total of 752 patients were diagnosed with sarcopenic obesity among 3354 participants. The patients were grouped by sex-specific ICW median levels, and the prevalence of sarcopenic obesity was significantly higher in the low ICW group than in the high ICW group (41.3%vs 3.0%). Decreased ICW was significantly associated with sarcopenic obesity. The association remained statistically significant even after adjusting for dialysis vintage, age, body mass index, biochemical indicators, and various medical histories. The odds ratios of the low ICW group were much higher than those of the high ICW group in both males and females (P for trend < 0.001). The association was stable across subgroups, and the interaction analysis showed that age, body mass index and history of diabetes had interactive roles in the association between ICW and sarcopenic obesity (P for interaction < 0.05). Furthermore, the ICW cut-off values for identifying sarcopenic obesity were 19.1 kg and 14.5 kg for males and females, respectively.

CONCLUSION

Decreased ICW was an independent risk factor for sarcopenic obesity in chronic HD patients. The measurement of ICW by bioimpedance spectroscopy might be a non-invasive and valid means for identifying the risk of future sarcopenic obesity in HD patients.

Design and methodology of the SARCopenia trajectories and associations with adverse clinical outcomes in patients on HemoDialysis: the SARC-HD study

BACKGROUND

Sarcopenia has been associated with adverse outcomes in patients with chronic kidney disease (CKD), particularly in those undergoing hemodialysis (HD). However, the trajectories across sarcopenia stages, their determinants, and associations with adverse clinical outcomes have yet to be comprehensively examined.

METHODS

The SARC-HD is a multicenter, observational prospective cohort study designed to comprehensively investigate sarcopenia in patients on HD. Eligibility criteria include adult patients undergoing HD for ≥ 3 months. The primary objective is to investigate the trajectories of sarcopenia stages and their potential determinants. Secondary objectives include evaluating the association between sarcopenia and adverse clinical outcomes (i.e., falls, hospitalization, and mortality). Sarcopenia risk will be assessed by the SARC-F and SARC-CalF questionnaire. Sarcopenia traits (i.e., low muscle strength, low muscle mass, and low physical performance) will be defined according to the revised European Working Group on Sarcopenia in Older People and will be assessed at baseline and after 12 follow-up months. Patients will be followed-up at 3 monthly intervals for adverse clinical outcomes during 24 months.

DISCUSSION

Collectively, we expect to provide relevant clinical findings for healthcare professionals from nephrology on the association between sarcopenia screening tools (i.e., SARC-F and SARC-CalF) with objective sarcopenia measurements, as well as to investigate predictors of trajectories across sarcopenia stages, and the impact of sarcopenia on adverse clinical outcomes. Hence, our ambition is that the data acquired from SARC-HD study will provide novel and valuable evidence to support an adequate screening and management of sarcopenia in patients on HD.

Central obesity as assessed by conicity index and a-body shape index associates with cardiovascular risk factors and mortality in kidney failure patients

Background

Anthropometric indices of central obesity, waist circumference (WC), conicity index (CI), and a-body shape index (ABSI), are prognostic indicators of cardiovascular (CV) risk. The association of CI and ABSI with other CV risk indices, markers of nutritional status and inflammation, and clinical outcomes in chronic kidney disease (CKD) stage 5 (CKD5) patients was investigated.

Methods

In a cross-sectional study with longitudinal follow up of 203 clinically stable patients with CKD5 (median age 56 years; 68% males, 17% diabetics, 22% with CV disease, and 39% malnourished), we investigated CI and ABSI and their associations with atherogenic index of plasma (AIP), Framingham CV risk score (FRS), Agatston scoring of coronary artery calcium (CAC) and aortic valve calcium (AVC), handgrip strength (HGS), high sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6). CV events (CVE) and all-cause mortality during up to 10-years follow up were analyzed by multivariate survival analysis of restricted mean survival time (RMST).

Results

Chronic kidney disease patients with middle and highest CI and ABSI tertiles (indicating greater abdominal fat deposition), compared to those with the lowest CI and ABSI tertiles, tended to be older, more often men and diabetic, had significantly higher levels of hsCRP, IL-6, AIP, FRS, CAC and AVC scores. CI and ABSI were positively correlated with CAC, FRS, AIP, hsCRP and IL-6. Both CI and ABSI were negatively correlated with HGS. In age-weighted survival analysis, higher CI and ABSI were associated with higher risk of CVE (Wald test = 4.92, p = 0.027; Wald test = 4.95, p = 0.026, respectively) and all-cause mortality (Wald test = 5.24, p = 0.022; Wald test = 5.19, p = 0.023, respectively). In RMST analysis, low vs. high and middle tertiles of CI and ABSI associated with prolonged CVE-free time and death-free time, and these differences between groups increased over time.

Conclusion

Abdominal fat deposit indices, CI and ABSI, predicted CV outcomes and all-cause mortality, and were significantly associated with the inflammatory status in CKD patients.

The Prevalence and Agreement of Sarcopenic Obesity Using Different Definitions and Its Association with Mild Cognitive Impairment

BACKGROUND

The consistent definition of sarcopenic obesity (SO) is limited, its association with mild cognitive impairment (MCI) has not been clarified.

OBJECTIVE

This study aimed to evaluate the prevalence and agreement of SO using different definitions and the association between SO and MCI.

METHODS

SO was diagnosed by the co-existence of sarcopenia defined by the Asia Working Group for Sarcopenia (AWGS) and obesity by body mass index (BMI), visceral fat area (VFA), waist circumference (WC), or body fat percentage (BF%). Cohen's kappa was used to assess the agreement between the different definitions. The association between SO and MCI was assessed using multivariable logistic regression.

RESULTS

Among 2,451 participants, the prevalence of SO ranged from 1.7% to 8.0% under different definitions. SO defined by AWGS and BMI (AWGS+BMI) showed fair agreements with the other three criteria (κ ranged from 0.334 to 0.359). The other criteria showed good agreements with each other. The κ statistics were 0.882 for AWGS+VFA and AWGS+BF%, 0.852 for AWGS+VFA and AWGS+WC, and 0.804 for AWGS+BF% and AWGS+WC, respectively. When using different diagnoses of SO, compared with the health group, the adjusted ORs of MCI for SO were 1.96 (95% CI: 1.29-2.99, SO: AWGS+WC), 1.75 (95% CI: 1.14-2.68, SO: AWGS+VFA), 1.94 (95% CI: 1.29-2.93, SO: AWGS+BF%), and 1.45 (95% CI: 0.67-3.12, SO: AWGS+BMI), respectively.

CONCLUSION

Using different obesity indicators combined with AWGS to diagnose SO, BMI had lower prevalence and agreement compared with other three indicators. SO was associated with MCI under different methods (WC, VFA, or BF%).

The prevalence of low muscle mass associated with obesity in the USA

BACKGROUND

Sarcopenia is defined as age-related low muscle mass and function, and can also describe the loss of muscle mass in certain medical conditions, such as sarcopenic obesity. Sarcopenic obesity describes loss of muscle and function in obese individuals; however, as sarcopenia is an age-related condition and obesity can occur in any age group, a more accurate term is obesity with low lean muscle mass (OLLMM). Given limited data on OLLMM (particularly in those aged < 65 years), the purpose of this study was to estimate the prevalence of OLLMM in adults aged ≥ 20 years in the USA.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) 2017-2018 and 1999-2006 were used. OLLMM was defined as an appendicular lean mass, adjusted for body mass index (BMI), cut-off point < 0.789 for males and < 0.512 for females, measured by dual-energy X-ray absorptiometry (DXA). DXA was only measured in individuals 20-59 years old in NHANES 2017-2018; we therefore utilized logistic regression models to predict OLLMM from NHANES 1999-2006 for those aged ≥ 60 years. The prevalence of OLLMM was estimated overall, and by sex, age, race/ethnicity, and clinical subgroup (high BMI, prediabetes, type 2 diabetes mellitus [T2DM], non-alcoholic fatty liver disease [NAFLD] with fibrosis, or post-bariatric surgery). Prevalence estimates were extrapolated to the USA population using NHANES sampling weights.

RESULTS

We estimated that, during 2017-2018, 28.7 million or 15.9% of the USA population had OLLMM. The prevalence of OLLMM was greater in older individuals (8.1%, aged 20-59 years vs 28.3%, aged ≥ 60 years), highest (66.6%) in Mexican-American females aged ≥ 60 years, and lowest (2.6%) in non-Hispanic Black males aged 20-59 years. There was a higher prevalence of OLLMM in adults with prediabetes (19.7%), T2DM (34.5%), NAFLD with fibrosis (25.4%), or post-bariatric surgery (21.8%), compared with those without each condition.

CONCLUSIONS

Overall, the burden of OLLMM in the USA is substantial, affecting almost 30 million adults. The prevalence of OLLMM increased with age, and among those with prediabetes, T2DM, NAFLD with fibrosis, or post-bariatric surgery. A unified definition of OLLMM will aid diagnosis and treatment strategies.

Sarcopenia and sarcopenic obesity in chronic kidney disease: update on prevalence, outcomes, risk factors and nutrition treatment

PURPOSE OF REVIEW

This review summarizes literature from the last 18 months reporting on sarcopenia (or its components) in chronic kidney disease (CKD).

RECENT FINDINGS

The prevalence of sarcopenia in CKD is reported to be 5-62.5%, with higher rates observed later in the disease. Sarcopenic obesity rates are reported to be 2-23%. Sarcopenia in CKD is associated with increased risk of mortality, cardiovascular disease and vascular calcification. Risk factors include kidney disease itself and the impacts of CKD on lifestyle (reduced physical activity, diet changes). In earlier stages of CKD, if the risks from sarcopenia outweigh the risk of reaching end-stage renal disease, ensuring adequate energy intake combined with modest protein liberalization and physical activity may be indicated. Protein intakes above 1.3 g/kg of body weight per day should be avoided. For dialysis patients, interventions that provide a combination of carbohydrate, protein and fat appear more effective than those that provide protein alone, though it may take as long as 48 weeks for detectable changes in muscle mass.

SUMMARY

Sarcopenia is prevalent in CKD as kidney disease significantly impacts muscle mass and function. Nutrition interventions can improve components of sarcopenia, with an emphasis on adequate energy and protein.

Comparison of frailty, sarcopenia and protein energy wasting in a contemporary peritoneal dialysis cohort

BACKGROUND

More elderly frail patients are now treated by peritoneal dialysis (PD). Frailty, sarcopenia and protein energy wasting (PEW) are all associated with increased mortality. Simple screening tools are required to identify patients to allow for interventions. As such, we wished to review the prevalence of frailty and compare frailty with sarcopenia and PEW in a contemporary PD population.

PATIENTS AND METHODS

We used the Clinical Frailty Score (CFS) to determine frailty, bio-impedance body composition and hand grip strength (HGS) to determine sarcopenia and combining laboratory, body composition and protein nitrogen appearance rate (PNA) to assess PEW.

RESULTS

Records of 368 PD patients, 61% male, mean age 60.9 ± 16.1 years, body mass index (BMI) 26.2 ± 5.1 kg/m² were reviewed, with 71 classified as frail (19.3%; CFS > 4), and frailty associated with age (odds ratio (OR) 1.047, 95% confidence interval (CL) 1.01-1.085, p = 0.012), Stoke-Davies co-morbidity (OR 1.808, 95%CL 1.129-2.895, p = 0.014) and negatively with HGS (OR 0.906, 95% CL 0.897-0.992, p = 0.033); 17.7% met muscle loss and HGS criteria for sarcopenia, with fair agreement with frailty (kappa 0.24 (CL 0.09-0.38)). Only two patients (0.5%) met all four criteria for PEW, 26.1% met the reduced BMI criteria, 4.6% the serum albumin, 32.9% the PNA and 39.4% the reduced muscle mass. HGS correlated with lean muscle mass (r ² = 0.42, p < 0.001).

CONCLUSION

Using the CFS, 19.3% of patients were classified as frail, compared to 17.7% with sarcopenia and <1% with PEW. The CFS requires no special equipment or laboratory tests and was associated with age, co-morbidity and HGS weakness.

Application of the Clinical Frailty Score and body composition and upper arm strength in haemodialysis patients

Background

To improve outcomes, simple screening tests are required to detect patients at increased risk of mortality. As patients with muscle weakness and wasting are at increased risk of death, we wished to review the use of the Clinical Frailty Score (CFS).

Patients and methods

Dialysis staff graded haemodialysis (HD) patients attending for routine outpatient sessions using the CFS, a functional scoring scale, for patients who require help with their instrumental activities of daily living, classified as clinically frail with scores >4, which were compared with contemporaneous Stoke–Davies comorbidity scores, post-HD body composition measured by bioimpedance, hand grip strength (HGS) and standard laboratory investigations.

Results

The results from 2089 patients (60.2% male) were reviewed, with 890 (42.6%) classified as frail. Frail patients were older [mean ± standard deviation (SD) 71.5 ± 15.6 versus 59.1 ± 15.6 years) and female (50.7% versus 37.3%) and had greater comorbidity {median 2 [interquartile range (IQR) 1–3] versus 1 [0–2]}, body mass index (BMI) (26.0 ± 6.7 versus 25.5 ± 5.4 kg/m²),  C-reactive protein (CRP) [8 (IQR 3–20) versus 5 (2–11) mg/L], lower serum albumin (37.6 ± 4.7 versus 40.1 ± 4.7 g/L),  lean BMI (8.9 ± 1.7 versus 9.7 ± 1.6 kg/m²) and HGS [13.4 (IQR 9.6–18.8) versus 20.9 (14.5–29) kg] (all P < 0.001). Frailty was independently associated in a multivariable logistic model with age {odds ratio [OR] 2.33 [95% confidence limit (CL) 2.01–2.7]}, body fat mass [OR 1.02 (CL 1.01–1.03)], log CRP [OR 1.63 (CL 1.28–2.07)] (all P < 0.001) and comorbidity [OR 1.45 (CL 1.17–1.8); P = 0.001] and negatively associated with albumin [OR 0.95 (CL 0.92–0.98) and HGS [OR 0.91 (CL 0.9–0.93)] (both P < 0.001).

Conclusion

Frail patients are at increased risk of mortality and, as such, simple reliable screening tools are required to rapidly detect patients at risk. The CFS is a useful screening tool that can be readily performed by dialysis staff to identify frail patients. Frailty in HD patients was associated with increasing age, comorbidity, fat weight and inflammation and reduced muscle strength and muscle mass. There is an overlap between frailty and both sarcopenia and protein energy wasting, which requires additional assessments, potentially including body composition, strength, dietary assessments and laboratory investigations. In addition, as the CFS offers a scale, patient trajectories can potentially be serially monitored over time, thus allowing patient-specific interventions or holistic care plans.